Important aspects of organ-preserving surgery for renal tumors: indications, new standards, and oncological outcomes

Abstract

Introduction: Organ-preserving surgery for renal tumors has become more common over the past two decades. At first, part of the kidney, rather than all of it, was resected only if there was an absolute indication for doing so, i.e., if the tumor was located in an anatomically or functionally solitary kidney or if renal failure was already present. Now that favorable oncological outcomes have been demonstrated, renal tumors are increasingly often removed with only partial resection of renal tissue even when the indications are less stringent, including when the other kidney is healthy.

Methods: The indications for, and oncological outcomes of, partial renal resection are presented and discussed on the basis of a selective literature search of Medline as well as the guidelines of the European Association of Urologists (EAU).

Results and conclusions: The EAU, in its new guidelines for renal cell carcinoma, recommends partial renal resection as the standard treatment for tumors less than 4 cm in size that are wholly contained within one kidney when the other kidney is healthy. This practice yields comparable outcomes to those of nephrectomy, with tumor-specific five-year survival rates exceeding 90%. In major urological centers, partial resection is favored even for tumors larger than 4 cm, as long as they are in a favorable location. Nonetheless, the estimated rate of nephrectomy for tumors less than 4 cm in size currently remains very high in Germany, as it does in American studies, even though the organ-preserving resection of such small tumors usually results in cure.

Keywords: life expectancy; renal cancer; renal failure; surgery; treatment outcomes.

Figures

Figure 1

Abdominal CT scan revealing a peripheral tumor in the left kidney of maximal diameter 5.4 cm (red circle) and a normal right kidney, illustrating the good resectability of a tumor exceeding 4 cm in size (extended elective indication). From: Becker F et al.: Organerhaltende Nierentumorchirurgie. Urologe A 2008; 47: 215–23; [22], with the kind permission of Springer Verlag, Heidelberg, Germany.

Figure 2

(a) A 6 cm tumor at the lower pole of the kidney, seen upon exposure of the kidney (red arrows, tumor; dotted line, border between normal renal parenchyma and tumor). The peritumoral fat is left attached to the specimen. (b) The resection bed after the tumor has been completely removed up to healthy tissue and vascular sutures have been laid in the resection bed.

Figure 3

Comparison of survival rates after elective partial nephrectomy and total nephrectomy (p